The Design And Implementation Of A Medical Insurance Charging And Management System

With further reformation on medical insurance system, the coverage of medical insurance system is becoming wider and wider. The number of members who are subscribed to this insurance system quickly increased. It became a hot topic on how can a medical insurance charging system respond to big numbers of concurrent settlements directed from client-ends. In the meantime, the expenditure of Medical Insurance Fund grows fast. As a result, the management of medical insurance is being emphasized by related organizations in many cities. However, the management of Medical Insurance Fund still relies on statistics provided by regular forms and reports. There's an absence of a systematic Medical Insurance Fund management and control system.The following thesis discussed the design and implementation of version 2.0 of Suzhou Industrial Park Medical Insurance Charging and Management System, which is based on a three-layer structure of the version 1.0. By introducing the Tuxedo middleware platform, using message queue asynchronous communication and two-stage submit scheme to ensure response to large amount of concurrent requests, the version 2.0 tackles the problem of settlement module fail to response to big amount of concurrent transactions in version 1.0. A scheme of data synchronizing of hospital front end processor is designed to assure in the occasion of network disconnection between hospital and medical insurance center, the settlement transaction of medical insurance members won't be affected.In the meantime, to reasonably control the expenditure on major illness fund, based on study on data mining related theory, after analysis on history data of medical insurance reimbursement on major illness claim, Pro-Apriori related algorithm was used to find out correlations between illness type, medicine and treatment used, and built a correlated database on illness type, medicine and treatment. Using correlation database and K-means algorithm to analyze every hospital's inpatient cases in the previous year, and use the analysis result to rate hospital's credibility. Divide them into good, middle and bad respectively and build the hospital credibility database. In the end, the thesis provided an improved settlement transaction procedure, and system will not respond to claims from hospitals with middle or low credibility, in the cases that they try to use medicines or treatments which are irrelevant to illness identified.The Medical Insurance Charging and Management 2.0 Version discussed and implemented in this thesis is now operating in Suzhou Industrial Park. The result is satisfactory, the system maintained normal operation when facing concurrent transactions from big number of users. In the meantime, new management approach added to the system can reasonably control expenditure from major illness fund, which is a new experiment in medical insurance management, and provided not only theory reference but also detail implementation to design and development on similar system.